Hurricane Jill

Partly cloudy and cool, with a 70% chance of social retardation

Yesterday, or maybe a couple of days ago–it all runs together when you take call three times in one seven day stretch, I had a rather long conversation with someone at work. Professionally, I like this guy, and personally we get along well. He’s also a very un-private person who talks freely about his life outside of work, so I know a lot more about him than he knows about me.

Well, the other day we were stuck together waiting for a patient to get scanned, and he started asking me all kinds of questions about myself. What I think of this program, whether I want to stay here, where I came from, why I’m interested in neurosurgery, do I have kids or a significant other, etc. Those of you who know me, know that when I talk to people, I tend to reflect their tone and level of openness in my own speech. So I pretty much told him exactly what I was thinking, which was not particularly wise or advantageous of me, politically. And socially it was entirely retarded of me, although at the time honesty seemed like the only respectable option.

But oh well, I guess at some point you have to let down your guard with people. Particularly when your job consumes as much of your life as neurosurgery does.

No man is an island, not even if he’s a Republican

Go Margaret and Helen!  I just love those two old ladies and their liberal rants.  Then again, I just like old people in general.  They crack me up, because they say whatever the hell they want and really don’t give a shit whether you approve or not.  Which means that often times they say exactly what I’m thinking.

Except for my own parents, who drive me nuts with the exact same behavior.  The difference is that I feel like their behavior reflects on me somehow.  I worry that people think I’m secretly harboring the same opinions, because, you know, that’s the talk I heard at home.  And the reality is that my own values contrast pretty starkly with theirs in many ways.

Of course, the further away they get from the economically sheltered life of talented, intelligent and well-educated middle age adults, the less Republican their views become.  In contrast, there’s no explanation for my own political views, given that I’ve always led a fairly sheltered life in this respect.  I’ve just always been more aware of how easily it can all slip away in one random piece of bad luck, one random act of God, one natural disaster where you happened to be in the wrong place at the wrong time.

Certainly, there’s an element of individual control in all of these situations.  You can do like I did in New Orleans, and be aware what the risks are and pick a place to live that minimizes your risk of loss or harm.  But even so, your risk is significantly affected by other people choices as well, which you can’t control.  I didn’t have control of levee maintenance, or the city pumps.  I didn’t choose to try and piggyback Tulane’s entire medical curriculum on top of some other school’s very different educational philosophy and infrastructure.  I didn’t choose to bring the entire school back before there was a sufficient clinical volume and infrastructure to provide adequate clinical exposure and teaching.

But these are the kinds of decisions where the right choice is only evident in retrospect.  And what’s done is done. My point is that I’m acutely aware of the randomness inherent in life, and the whole point of having a safety net is that you never know when you’re going to need it.  And chances are that no matter how invincible and in control of your life you feel now, at some point you will fall.

This was brought home very starkly this past week, in which a resident in one of our programs sustained a severe brain injury.  He had done everything right, and still ended up in our ER with the kind of head injury that could have been fatal, or worse, nonfatal but neurologically devastating.  I had seen a similar thing happen at UW, although with a more severe injury and a different outcome.  That’s one of the hardest parts of neurosurgery: the knowledge that no matter what you do or don’t do, only occasionally are your patients totally normal again.

But that’s not the hardest part.  The hardest part is knowing that you made them worse off than they would have been without your intervention.  I mean, it sucks that we have basically the same number of patients as the general surgeons with only 1 resident in house compared to their 4, so it always feels like you’re being pulled in 5 directions at once.  And it sucks to have to explain in the morning why all 5 of those things didn’t get taken care of all at once like they needed to be.  But when you’re home and rested, it’s the people you harmed that haunt you.

Not that I have a lot of experience with that as yet.  Mostly it’s vicarious, when I examine somebody that has a new deficit that wasn’t there prior to the surgery.  But the attendings mentally flagellate themselves whenever it happens, and you can see it in their eyes.  Often times, they’ve done absolutely nothing wrong, and this is just that 1 in however many cases in which this adverse event occurs.  But for that one patient, it doesn’t matter how low the odds were.  Nor is it their fault, yet they have to live with the consequences.

So how you can be a Republican, and against truly universal health coverage, as well as other social safety nets, when every day you see before you evidence that we’re all just a heartbeat away from the kind of loss that lands you on welfare or disability for the rest of your life, is a mystery to me.

Patient management

Today was a bad day, for reasons that will probably seem a little ridiculous/arrogant/spoiled/some combination thereof.  I’m pissed off with myself today because two of my patients were worse off this morning than they were yesterday.

This kind of thing does not happen to me.  My patients who should get better, do.  And those who get worse or die do so because either we can’t save them no matter what we do, or we’ve chosen patient comfort as the treatment goal, rather than palliation or cure.

It’s those damn lungs again.  When patients start having pulmonary issues, some part of my brain goes, “Ack! Physics!” and just shuts down.  Which is silly, because I have a decent intuitive grasp of the processes involved, and am certainly capable of figuring out what’s going on.  I just, for whatever reason, feel intimidated by pulmonary issues, and therefore have a tendency to stand back and let other people solve that particular part of the patient’s critical care management.  And the end result is that I’m not very good at sorting out ICU patients once their lungs start causing problems.

This must stop.

As an intern, I was one of the ones whose patients rarely did poorly, and I like to think that it was because I was on top of their care.  I knew how to keep a small problem from becoming a big one, and could tell when something looked bad but didn’t mean anything.  And also, equally important, when something that seemed small and insignificant was actually an early warning sign of decompensation somewhere.

I do not have that level of clinical insight yet with critical care patients.  So I don’t know when to push back on a plan that I’m not sure is correct.  I don’t know at what point to call and say: the plan is not working, we need to reassess.  Nor is it even clear to me sometimes exactly what part of the plan is not working and needs reassessment.

Part of the problem is that some attendings’ plans seem to work better and more consistently than others.  And I can’t quite put my finger on why that is.  All I know is that with some attendings, patients always get better, the plan is clear and either I understand what’s going on and how to deal with it, or there is clearly a new problem.  With other attendings I end rounds more confused and fragmented in my thinking than when I began.

But really, that’s no different than when I was an intern dealing with various chief residents.  However, toward the end of intern year, I knew what I was doing, and so I relied far less on my chiefs for direction.  Plus I knew how to manage the people above me in order to avoid getting a poor plan for the problem in question. (Anyone who says that you don’t manage your chiefs and attendings is either clueless or lying.)  I’m gradually learning to do that here, but it’s one of a great many things I’m trying to learn at once.  And it’s not an excuse.

So I’ll just have to keep reading and trying to understand, and make a more dedicated effort to master pulmonary critical care.

How long before I begin, before it starts, before I get in?

This has been the strangest couple of weeks ever. First of all, last week I was assigned to clinic for nearly the entire week.

That’s why people go into surgery, you know.  For the clinic.   Continue Reading How long before I begin, before it starts, before I get in?…